Prevention of childhood overweight and obesity in Mongolia, the Philippines and Vietnam: identifying priority actions.

Low- and middle-income countries are increasingly faced with a triple burden of malnutrition: endemic underweight, micronutrient deficiencies and rising prevalence of overweight. This study aimed to address existing knowledge gaps and to identify priority policy options in Mongolia, the Philippines and Vietnam. A landscape analysis approach was adopted using methods set out in a UNICEF global toolkit. Quantitative and qualitative data were compiled from a range of global and national sources on childhood overweight and obesity, risk factors and policy responses. Key informant interviews and validation workshops were undertaken with key food and nutrition stakeholders from government and non-government organizations to identify priority policy options for the prevention of overweight and obesity among children. Overweight and obesity among children are increasing in all three countries. Associated risk factors are related to maternal nutrition, birthweight, breastfeeding, as well as diets and physical activity shaped by increasingly obesogenic environments. Key informants identified undefined policy approaches, poor community understanding and food and beverage industry influence as barriers to addressing overweight and obesity. Key policy priorities include restricting the marketing of unhealthy food and beverages, unhealthy food and beverage taxation, introduction of front-of-pack nutrition labels and improving school nutrition environments. Mongolia, the Philippines and Vietnam are all facing an increasing burden of childhood overweight and obesity. Despite differing national contexts, similar environmental factors are driving this rise. A suite of evidence-based policies can effectively be introduced to address obesogenic environments.

Priority actions for addressing the obesity epidemic in England.

OBJECTIVE: To prioritise policy actions for government to improve the food environment and contribute to reduced obesity and related diseases. DESIGN: Cross-sectional study applying the Food Environment Policy Index (Food EPI) in two stages. First, the evidence on all relevant policies was compiled, through an Internet search of government documents, and reviewed for accuracy and completeness by government officials. Second, independent experts were brought together to identify critical gaps and prioritise actions to fill those gaps, through a two-stage rating process. SETTING: England. SUBJECTS: A total of seventy-three independent experts from forty-one organisations were involved in the exercise. RESULTS: The top priority policy actions for government identified were: (i) control the advertising of unhealthy foods to children; (ii) implement the levy on sugary drinks; (iii) reduce the sugar, fat and salt content in processed foods (leading to an energy reduction); (iv) monitor school and nursery food standards; (v) prioritise health and the environment in the 25-year Food and Farming Plan; (vi) adopt a national food action plan; (vii) monitor the food environment; (viii) apply buying standards to all public institutions; (ix) strengthen planning laws to discourage less healthy food offers; and (x) evaluate food-related programmes and policies. CONCLUSIONS: Applying the Food EPI resulted in agreement on the ten priority actions required to improve the food environment. The Food EPI has proved to be a useful tool in developing consensus for action to address the obesity epidemic among a broad group of experts in a complex legislative environment.

Effectiveness and cost-effectiveness of interventions that cause weight loss and reduce the risk of cardiovascular disease.

BACKGROUND: Overweight/obesity is associated with significant morbidity, mortality and costs. Weight loss has been shown to reverse some of these effects, reducing the risk of chronic diseases such as cardiovascular disease (CVD). AIM: To determine the potential monies available, from an English National Health Service perspective, for weight loss interventions to be cost-effective in the prevention of CVD. METHODS: A Markov model was developed, populated with overweight/obese individuals from the Health Survey for England, aged 30-74 years, free of pre-existing CVD and with available risk factor information to calculate CVD risk. All individuals were free of CVD at baseline and, with each annual cycle, could transition to other health states of primary CVD, secondary CVD or death according to transition probabilities for a maximum period of 10 years, or until death. Utilities, costs and the effects of weight loss on CVD risk factors were applied. The potential monies available for CVD prevention strategies, provided the incremental cost-effectiveness ratio met UK arbitrary limits of between £20 000 and £30 000, was determined. RESULTS: Applying the effects of weight loss on CVD risk factors prevented 4 CVD events and saved 17 quality-adjusted life-years over 10 years per 1000 individuals. £34 to £51 was available per person per year for up to 10 years when meeting the UK arbitrary limits. CONCLUSIONS: Individual annual financial allowances for weight loss interventions to be considered cost-effective is relatively low; however, as a large proportion of the population is affected, wide cheap societal interventions are important.

Strengthening of accountability systems to create healthy food environments and reduce global obesity.

To achieve WHO's target to halt the rise in obesity and diabetes, dramatic actions are needed to improve the healthiness of food environments. Substantial debate surrounds who is responsible for delivering effective actions and what, specifically, these actions should entail. Arguments are often reduced to a debate between individual and collective responsibilities, and between hard regulatory or fiscal interventions and soft voluntary, education-based approaches. Genuine progress lies beyond the impasse of these entrenched dichotomies. We argue for a strengthening of accountability systems across all actors to substantially improve performance on obesity reduction. In view of the industry opposition and government reluctance to regulate for healthier food environments, quasiregulatory approaches might achieve progress. A four step accountability framework (take the account, share the account, hold to account, and respond to the account) is proposed. The framework identifies multiple levers for change, including quasiregulatory and other approaches that involve government-specified and government-monitored progress of private sector performance, government procurement mechanisms, improved transparency, monitoring of actions, and management of conflicts of interest. Strengthened accountability systems would support government leadership and stewardship, constrain the influence of private sector actors with major conflicts of interest on public policy development, and reinforce the engagement of civil society in creating demand for healthy food environments and in monitoring progress towards obesity action objectives.

Child and adolescent obesity: part of a bigger picture.

The prevalence of childhood overweight and obesity has risen substantially worldwide in less than one generation. In the USA, the average weight of a child has risen by more than 5 kg within three decades, to a point where a third of the country's children are overweight or obese. Some low-income and middle-income countries have reported similar or more rapid rises in child obesity, despite continuing high levels of undernutrition. Nutrition policies to tackle child obesity need to promote healthy growth and household nutrition security and protect children from inducements to be inactive or to overconsume foods of poor nutritional quality. The promotion of energy-rich and nutrient-poor products will encourage rapid weight gain in early childhood and exacerbate risk factors for chronic disease in all children, especially those showing poor linear growth. Whereas much public health effort has been expended to restrict the adverse marketing of breastmilk substitutes, similar effort now needs to be expanded and strengthened to protect older children from increasingly sophisticated marketing of sedentary activities and energy-dense, nutrient-poor foods and beverages. To meet this challenge, the governance of food supply and food markets should be improved and commercial activities subordinated to protect and promote children's health.

Progress achieved in restricting the marketing of high-fat, sugary and salty food and beverage products to children.

In May 2010, 192 Member States endorsed Resolution WHA63.14 to restrict the marketing of food and non-alcoholic beverage products high in saturated fats, trans fatty acids, free sugars and/or salt to children and adolescents globally. We examined the actions taken between 2010 and early 2016 - by civil society groups, the World Health Organization (WHO) and its regional offices, other United Nations (UN) organizations, philanthropic institutions and transnational industries - to help decrease the prevalence of obesity and diet-related noncommunicable diseases among young people. By providing relevant technical and policy guidance and tools to Member States, WHO and other UN organizations have helped protect young people from the marketing of branded food and beverage products that are high in fat, sugar and/or salt. The progress achieved by the other actors we investigated appears variable and generally less robust. We suggest that the progress being made towards the full implementation of Resolution WHA63.14 would be accelerated by further restrictions on the marketing of unhealthy food and beverage products and by investing in the promotion of nutrient-dense products. This should help young people meet government-recommended dietary targets. Any effective strategies and actions should align with the goal of WHO to reduce premature mortality from noncommunicable diseases by 25% by 2025 and the aim of the UN to ensure healthy lives for all by 2030.

En mai 2010, 192 États membres ont ratifié la Résolution WHA63.14 pour restreindre, à l'échelle internationale, la commercialisation des produits alimentaires et boissons non alcoolisées riches en graisses saturées, en acides gras trans, en sucres libres et/ou en sel, destinés aux enfants et aux adolescents. Nous avons étudié des initiatives d'organisations de la société civile, de l'Organisation mondiale de la Santé (OMS) et de ses bureaux régionaux, d'autres agences de l'Organisation des Nations unies (ONU), d'institutions philanthropiques et de groupes industriels internationaux, menées entre 2010 et début 2016 en vue d'aider à réduire la prévalence de l'obésité et des maladies non transmissibles liées à l'alimentation chez les jeunes. En fournissant aux États membres des outils et des conseils utiles en matière technique et pour l'adoption de mesures politiques, l'OMS et d'autres agences de l'ONU ont contribué à protéger les jeunes face à la commercialisation d'aliments et de boissons de marques, riches en graisses, en sucre et/ou en sel. Les résultats obtenus grâce aux initiatives des autres acteurs étudiés semblent variables et généralement moins solides. Nous suggérons d'accélérer les progrès accomplis vers la mise en œuvre complète de la Résolution WHA63.14, en restreignant davantage la commercialisation des aliments et boissons mauvais pour la santé et en investissant dans la promotion de produits denses sur le plan nutritionnel. Cela permettrait d'aider les jeunes à atteindre les objectifs nutritionnels recommandés par les gouvernements. Pour être efficaces, les stratégies et mesures adoptées doivent être cohérentes avec l'objectif de l'OMS visant à réduire la mortalité prématurée due aux maladies non transmissibles de 25% d'ici 2025 et avec l'objectif de l'ONU visant à permettre à tous de vivre en bonne santé d'ici 2030.

En mayo de 2010, 192 Estados Miembros aprobaron la Resolución WHA63.14 para limitar la promoción de alimentos y bebidas no alcohólicas con elevadas cantidades de grasas saturadas, ácidos grasos trans, azúcares libres y/o sal dirigida a los niños y adolescentes de todo el mundo. Se examinaron las medidas tomadas entre 2010 y principios de 2016 por parte de grupos de la sociedad civil, la Organización Mundial de la Salud (OMS) y sus sedes regionales, otras organizaciones de las Naciones Unidas, instituciones filantrópicas e industrias transnacionales para contribuir a la reducción de la prevalencia de la obesidad y enfermedades no contagiosas relacionadas con la alimentación entre los jóvenes. Mediante las directrices y herramientas políticas y técnicas correspondientes ofrecidas a los Estados Miembros, la OMS y otras organizaciones de las Naciones Unidas han ayudado a proteger a los jóvenes de la promoción de productos alimentarios y bebidas de marca con elevadas cantidades de grasa, azúcar y/o sal. Los progresos realizados por los otros participantes investigados parecen ser desiguales y, en general, menos sólidos. Nuestra sugerencia es que el progreso hacia la implementación completa de la Resolución WHA63.14 se acelere limitando aún más la promoción de productos alimentarios y bebidas insanos y se invierta en la promoción de productos altamente nutritivos. Esto debería ayudar a los jóvenes a alcanzar los objetivos nutricionales recomendados por los gobiernos. Todas las estrategias y medidas eficaces deberían ajustarse a la meta de la OMS de reducir la mortalidad prematura provocada por enfermedades no contagiosas en un 25% en 2015 y el objetivo de las Naciones Unidas de garantizar una vida sana para todos en 2030.

Potential health gains and health losses in eleven EU countries attainable through feasible prevalences of the life-style related risk factors alcohol, BMI, and smoking: a quantitative health impact assessment.

BACKGROUND: Influencing the life-style risk-factors alcohol, body mass index (BMI), and smoking is an European Union (EU) wide objective of public health policy. The population-level health effects of these risk-factors depend on population specific characteristics and are difficult to quantify without dynamic population health models. METHODS: For eleven countries-approx. 80 % of the EU-27 population-we used evidence from the publicly available DYNAMO-HIA data-set. For each country the age- and sex-specific risk-factor prevalence and the incidence, prevalence, and excess mortality of nine chronic diseases are utilized; including the corresponding relative risks linking risk-factor exposure causally to disease incidence and all-cause mortality. Applying the DYNAMO-HIA tool, we dynamically project the country-wise potential health gains and losses using feasible, i.e. observed elsewhere, risk-factor prevalence rates as benchmarks. The effects of the "worst practice", "best practice", and the currently observed risk-factor prevalence on population health are quantified and expected changes in life expectancy, morbidity-free life years, disease cases, and cumulative mortality are reported. RESULTS: Applying the best practice smoking prevalence yields the largest gains in life expectancy with 0.4 years for males and 0.3 year for females (approx. 332,950 and 274,200 deaths postponed, respectively) while the worst practice smoking prevalence also leads to the largest losses with 0.7 years for males and 0.9 year for females (approx. 609,400 and 710,550 lives lost, respectively). Comparing morbidity-free life years, the best practice smoking prevalence shows the highest gains for males with 0.4 years (342,800 less disease cases), whereas for females the best practice BMI prevalence yields the largest gains with 0.7 years (1,075,200 less disease cases). CONCLUSION: Smoking is still the risk-factor with the largest potential health gains. BMI, however, has comparatively large effects on morbidity. Future research should aim to improve knowledge of how policies can influence and shape individual and aggregated life-style-related risk-factor behavior.

The assessment of ongoing community-based interventions to prevent obesity: lessons learned.

BACKGROUND: The assessment of real-life, community-based interventions to tackle obesity is an important step in the development of effective policies. Especially multi-level interventions have a high likely effectiveness and potential reach in counteracting the obesity epidemic. Although much can be learned from these initiatives, performing an evaluation of such interventions is challenging. The aim of the current article is to provide a descriptive overview of the data collection process and general results of an assessment of ongoing multi-level obesity prevention community interventions for adults in Europe, and the lessons learned from this effort. METHODS: The data collection was divided into two main phases: a) finding the ongoing obesity prevention interventions by contacting key informants in each of the European Union countries and the European Economic Area, and searching existing databases; and b) collecting detailed information (including the reach, effectiveness, adoption, implementation and maintenance (RE-AIM)) of the selected interventions using questionnaires for informants in each of the interventions. RESULTS: A total of 78 interventions from 24 European countries were included in the final sample. The number of identified interventions varied greatly per country. The interventions covered various implementation levels (national, regional or local) and determinants (physical, sociocultural, economic, political), mostly addressing both nutrition and physical activity behaviours. CONCLUSIONS: We found that many multi-level obesity prevention interventions among adults are currently active in Europe, although we found relatively few in Southern and Eastern Europe. Identifying interventions and obtaining detailed information proved to be a difficult, time consuming and painstaking process. We discuss some of the reasons why this might be the case and present recommendations based on our experiences. We suggest that future research uses a step-wise approach, keeping participant burden to a minimum. The use of personalised and tailored strategies is recommended, led by researchers who exercise flexibility, tact and patience during the data collection process.

The impact of marketing practices and its regulation policies on childhood obesity. Opinions of stakeholders in Spain.

The aim of this study was to identify Spanish stakeholders' views on the relationship between childhood obesity and the marketing and advertising of food and beverages aimed at children in Spain, as well as on the corresponding of regulations. We performed a qualitative study based on semi-structured interviews with Stakeholders/Key Informants (KI) from 13 organisations: experts (2), consumer advocates (1), public health advocates (2), food manufacturers (2), advertising advocates (1), government representatives (1), child/family/school advocates (2) and media (1). The variables studied were Prevalence of childhood obesity and its relationship to marketing/advertising and Regulation of marketing. In order to identify the most relevant arguments (pearls) in the discourses, a blind independent analysis by four members of the research team was performed. We found that the prevalence of childhood obesity was perceived to be higher than the European average. Self-regulation was identified as the main form of marketing control. Only food manufacturers and advertising agencies considered voluntary action and supervisory procedures to be effective. The other stakeholders advocated state control through legislation and non-state actions such as external assessment and sanctions. Despite the divergence of opinion between stakeholders, there was agreement on the need to improve supervision and to ensure compliance with current self-regulatory codes in Spain.

An improved algorithm to harmonize child overweight and obesity prevalence rates.

BACKGROUND: Prevalence rates of child overweight and obesity for a group of children vary depending on the BMI reference and cut-off used. Previously we developed an algorithm to convert prevalence rates based on one reference to those based on another. OBJECTIVE: To improve the algorithm by combining information on overweight and obesity prevalence. METHODS: The original algorithm assumed that prevalence according to two different cut-offs A and B differed by a constant amount dz on the z-score scale. However the results showed that the z-score difference tended to be greater in the upper tail of the distribution and was better represented by b × dz , where b was a constant that varied by group. The improved algorithm uses paired prevalence rates of overweight and obesity to estimate b for each group. Prevalence based on cut-off A is then transformed to a z-score, adjusted up or down according to b × dz and back-transformed, and this predicts prevalence based on cut-off B. The algorithm's performance was tested on 228 groups of children aged 6-17 years from 20 countries. RESULTS: The revised algorithm performed much better than the original. The standard deviation (SD) of residuals, the difference between observed and predicted prevalence, was 0.8% (n = 2320 comparisons), while the SD of the difference between pairs of the original prevalence rates was 4.3%, meaning that the algorithm explained 96.7% of the baseline variance (88.2% with original algorithm). CONCLUSIONS: The improved algorithm appears to be effective at harmonizing prevalence rates of child overweight and obesity based on different references.

Obesogens and Obesity: State-of-the-Science and Future Directions Summary from a Healthy Environment and Endocrine Disruptors Strategies Workshop.

On September 7 and 8, 2022, Healthy Environment and Endocrine Disruptors Strategies, an Environmental Health Sciences program, convened a scientific workshop of relevant stakeholders involved in obesity, toxicology, or obesogen research to review the state of the science regarding the role of obesogenic chemicals that might be contributing to the obesity pandemic. The workshop's objectives were to examine the evidence supporting the hypothesis that obesogens contribute to the etiology of human obesity; to discuss opportunities for improved understanding, acceptance, and dissemination of obesogens as contributors to the obesity pandemic; and to consider the need for future research and potential mitigation strategies. This report details the discussions, key areas of agreement, and future opportunities to prevent obesity. The attendees agreed that environmental obesogens are real, significant, and a contributor at some degree to weight gain at the individual level and to the global obesity and metabolic disease pandemic at a societal level; moreover, it is at least, in theory, remediable.

Sustainable prevention of obesity through integrated strategies: The SPOTLIGHT project's conceptual framework and design.

BACKGROUND: The prevalence of overweight and obesity in Europe is high. It is a major cause of the overall rates of many of the main chronic (or non communicable) diseases in this region and is characterized by an unequal socio-economic distribution within the population. Obesity is largely determined by modifiable lifestyle behaviours such as low physical activity levels, sedentary behaviour and consumption of energy dense diets. It is increasingly being recognised that effective responses must go beyond interventions that only focus on a specific individual, social or environmental level and instead embrace system-based multi-level intervention approaches that address both the individual and environment. The EU-funded project "sustainable prevention of obesity through integrated strategies" (SPOTLIGHT) aims to increase and combine knowledge on the wide range of determinants of obesity in a systematic way, and to identify multi-level intervention approaches that are strong in terms of Reach, Efficacy, Adoption, Implementation and Maintenance (RE-AIM). METHODS/DESIGN: SPOTLIGHT comprises a series of systematic reviews on: individual-level predictors of success in behaviour change obesity interventions; social and physical environmental determinants of obesity; and on the RE-AIM of multi-level interventions. An interactive web-atlas of currently running multi-level interventions will be developed, and enhancing and impeding factors for implementation will be described. At the neighbourhood level, these elements will inform the development of methods to assess obesogenicity of diverse environments, using remote imaging techniques linked to geographic information systems. The validity of these methods will be evaluated using data from surveys of health and lifestyles of adults residing in the neighbourhoods surveyed. At both the micro- and macro-levels (national and international) the different physical, economical, political and socio-cultural elements will be assessed. DISCUSSION: SPOTLIGHT offers the potential to develop approaches that combine an understanding of the obesogenicity of environments in Europe, and thus how they can be improved, with an appreciation of the individual factors that explain why people respond differently to such environments. Its findings will inform governmental authorities and professionals, academics, NGOs and private sector stakeholders engaged in the development and implementation of policies to tackle the obesity epidemic in Europe.

What is a "high" prevalence of obesity? Two rapid reviews and a proposed set of thresholds for classifying prevalence levels.

Categories such as "low" and "high" have been used for several decades to describe the prevalence of stunting and wasting in populations of children aged under 5 years. They provide support for public health risk assessment and policy-making, including alerting health departments and aid agencies to national trends and local needs. In the light of the need for monitoring progress to meet globally agreed targets for overweight and obesity, the classification of their prevalence will be a valuable to aid in policy development, to target resources, and to promote public health interventions. This paper reviews the current use of categories to describe obesity prevalence in policy, advocacy, and research literature. Where prevalence categories have been formally proposed, this paper compares their application on large-scale datasets. The paper then develops a set of recommended threshold values to classify prevalence levels for overweight and obesity among children under age 5 years, children aged 5-19 years, and adults.

Exploring an algorithm to harmonize International Obesity Task Force and World Health Organization child overweight and obesity prevalence rates.

BACKGROUND: The International Obesity Task Force (IOTF) and World Health Organization (WHO) body mass index (BMI) cut-offs are widely used to assess child overweight, obesity and thinness prevalence, but the two references applied to the same children lead to different prevalence rates. OBJECTIVES: To develop an algorithm to harmonize prevalence rates based on the IOTF and WHO cut-offs, to make them comparable. METHODS: The cut-offs are defined as age-sex-specific BMI z-scores, for example, WHO +1 SD for overweight. To convert an age-sex-specific prevalence rate based on reference cut-off A to the corresponding prevalence based on reference cut-off B, first back-transform the z-score cut-offs zA and zB to age-sex-specific BMI cut-offs, then transform the BMIs to z-scores zB,A and zA,B using the opposite reference. These z-scores together define the distance between the two cut-offs as the z-score difference dzA,B=12zB-zA+zA,B-zB,A . Prevalence in the target group based on cut-off A is then transformed to a z-score, adjusted up or down according to dzA,B and back-transformed, and this predicts prevalence based on cut-off B. The algorithm's performance was tested on 74 groups of children from 14 European countries. RESULTS: The algorithm performed well. The standard deviation (SD) of the difference between pairs of prevalence rates was 6.6% (n = 604), while the residual SD, the difference between observed and predicted prevalence, was 2.3%, meaning that the algorithm explained 88% of the baseline variance. CONCLUSIONS: The algorithm goes some way to addressing the problem of harmonizing overweight and obesity prevalence rates for children aged 2-18.

A better understanding of the science and reality of obesity is urgently needed.

Efforts to prevent and treat obesity need to be grounded in science. A historical focus on individual responsibility has been ineffective in halting the rise in obesity prevalence. There needs to be a better understanding of environmental and biological drivers of weight gain to help reduce weight bias and stigma and identify more effective policies for action.

Research for food and health in Europe: themes, needs and proposals.

BACKGROUND: Diet, in addition to tobacco, alcohol and physical exercise, is a major factor contributing to chronic diseases in Europe. There is a pressing need for multidisciplinary research to promote healthier food choices and better diets. Food and Health Research in Europe (FAHRE) is a collaborative project commissioned by the European Union. Among its tasks is the description of national research systems for food and health and, in work reported here, the identification of strengths and gaps in the European research base. METHODS: A typology of nine research themes was developed, spanning food, society, health and research structures. Experts were selected through the FAHRE partners, with balance for individual characteristics, and reported using a standardised template. RESULTS: Countries usually commission research on food, and on health, separately: few countries have combined research strategies or programmes. Food and health are also strongly independent fields within the European Commission's research programmes. Research programmes have supported food and bio-technology, food safety, epidemiological research, and nutritional surveillance; but there has been less research into personal behaviour and very little on environmental influences on food choices - in the retail and marketing industries, policy, and regulation. The research is mainly sited within universities and research institutes: there is relatively little published research contribution from industry. DISCUSSION: National food policies, based on epidemiological evidence and endorsed by the World Health Organisation, recommend major changes in food intake to meet the challenge of chronic diseases. Biomedical and biotechnology research, in areas such as 'nutrio-genomics', 'individualised' diets, 'functional' foods and 'nutri-pharmaceuticals' appear likely to yield less health benefit, and less return on public investment, than research on population-level interventions to influence dietary patterns: for example policies to reduce population consumption of trans fats, saturated fats, salt and energy density. Research should now address how macro-diets, rather than micro-nutritional content, can be improved for beneficial impacts on health, and should evaluate the impact of market changes and policy interventions, including regulation, to improve public health. CONCLUSIONS: European and national research on food and health should have social as well as commercial benefits. Strategies and policies should be developed between ministries of health and national research funding agencies. Collaboration between member states in the European Union can yield better innovation and greater competitive advantage.